Periodontal Disease

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Periodontal Disease

WHAT IS PERIODONTAL DISEASE?

In order to clarify the various aspects and progression of the disease, an understanding of the anatomy of the region is helpful:

The Periodontium

The region of the mouth that consists of the gum and supporting structures is called the periodontium. It is made up of the following parts:

Gum ( gingiva). When healthy, the gingiva is pale pink, firm, and immobile, with a smooth or stippled texture. The gingival tissue between abutting teeth is shaped like a pyramid ending in a peak.
The crevice between the gum and tooth (the sulcus).
Root surface ( cementum).
Connective tissue attachments.
Bone. The crest of the supporting bone, which can be viewed on x-rays, is normally two millimeters below the point where the crown of the tooth meets the root (the cementoenamel junction).

Periodontal Disease

Periodontal disease refers to a group of problems that arise in the gum sulcus, the crevice between the gum and the tooth. Even in healthy mouths, the sulcus is teeming with bacteria, but they tend to be harmless varieties. Periodontal disease develops usually because of two events in the oral cavity:

An increase in bacteria quantity.
Change in the balance of bacterial types from harmless to disease-causing bacteria. [See What Causes Periodontal Disease?]

In general, the process that causes disease is as follows:

Harmful bacteria increase in mass and thickness until they form a film known as plaque.
In healthy mouths, plaque itself actually provides some barrier against outside bacterial invasion. When it accumulates to excessive levels, however, plaque adheres to the surfaces of the teeth and adjacent gingiva and causes cellular injury, with subsequent swelling, redness, and heat.
When plaque is allowed to remain in the periodontal area, it transforms into calculus (commonly known as tartar).
This material has a rock-like consistency and adheres tenaciously to the tooth surface. The color and hardness vary depending on the age of the material and extrinsic factors, such as tobacco use. It is much more difficult to remove than plaque, which is a soft amorphous mass.
Calculus produces injury and inflammation that eventually destroys the support structures and bone and can lead to tooth loss.

Periodontal diseases are generally divided into two groups:

Gingivitis, which causes lesions (wounds) that affect the gums.
Periodontitis, which damages the bone and connective tissue that supports the teeth.

Gingivitis

Gingivitis is an inflammation of the gingiva, or gums. Is nearly always chronic, but an acute form infrequently occurs.

Chronic Gingivitis . Ordinary chronic gingivitis affects over 90% of the population. It characterized by tender, red, swollen gums that bleed easily and may be responsible for bad breath ( halitosis) in some cases. Treatment is very effective if initiated early in the course of gingivitis. Without good management, however, the problem can progress.

Periodontitis

Periodontitis is characterized by the following:

Gum inflammation, with redness and bleeding.
Deep pockets (greater than 3 millimeters in depth) form between the gum and the tooth.
Loose teeth, caused by loss of connective tissue structures and bone.

Gingivitis precedes periodontitis, although it doesn't always lead to this more severe condition. In fact, some experts believe it is an entirely different disease. There are different categories of periodontal disease, including the following:

Chronic Periodontitis. Chronic periodontitis (also referred to as adult periodontitis) may begin in adolescence as a slowly progressing disease that becomes clinically significant in the mid-30's and continues throughout life. Some experts question whether it is a chronic unrelenting condition and suggest instead that it waxes and wanes depending on the response of the immune system in fighting the bacteria causing this disease.

Aggressive Periodontitis. Aggressive periodontitis (also referred to as early onset periodontitis) often occurs in young people. It is subdivided according to whether it begins before or after puberty. Immune deficiencies and a genetic link have been shown to be possible factors for all types of aggressive periodontitis. If the condition is localized and treated, the outlook is positive. People with severe and widespread aggressive periodontitis are at high risk for tooth loss. It is notable that according to a study in 2001, impaired infection-fighting white blood cells, together with bacterial presence, can lead to aggressive periodontitis.

Prepubertal periodontitis is a very rare condition that begins with the eruption of primary teeth in the first year and causes severe inflammation and bone and tooth loss.
Juvenile periodontitis (formerly known as periodontosis) begins at puberty and is defined by severe bone loss around the first molars and incisors. It is more common in girls than in boys. The clinical signs such as inflammation, bleeding, and heavy plaque accumulation are not present in this relatively rare disease. The treatment is the same as in chronic periodontitis.
Rapidly progressive periodontitis occurs in the early 20's to middle 30's. Severe inflammation and rapid bone and connective tissue loss occur, and tooth loss is possible within a year of onset.

Disease-Related Periodontitis. Periodontitis can also be associated with a number of systemic diseases, including type I diabetes mellitus, Down's syndrome, AIDS, and several rare disorders of white blood cells.

Acute Necrotizing Periodontal Disease. Acute necrotizing periodontal diseases is an acute infection in the gums. It is characterized by the following:

Black dead tissue (necrosis).
Spontaneous bleeding.
Rapid onset of pain.
Bad odor.
The gum tissue between the teeth, normally cone-shaped, is blunted.

Stress, poor diet, smoking, and viral infections are predisposing factors for this illness.

WHAT ARE THE SYMPTOMS OF PERIODONTAL DISEASE?

In general, symptoms progress over time and include the following:

Red and Swollen Gums . Initially, the gums are red and swollen as in gingivitis.
Gum Bleeding. Bleeding of the gums, even during brushing, is a sign of inflammation and the major marker of periodontal disease. One exception is juvenile periodontitis, in which symptoms are mild or even absent. It should be noted that the gums of smokers with periodontal disease tend to bleed less than nonsmokers.
Bad Breath. Debris and bacteria can cause a bad taste in the mouth and persistent bad breath.
Gum Recession and Loose Teeth. As the disease advances the gums recede, and supporting structure of bone is lost. Teeth loosen, sometimes causing a change in the way the upper and lower teeth fit together when biting down or a change in the fit of partial dentures.
Abscesses. Deepening periodontal pockets between the gums and bone can become blocked by tartar or food particles. The infection fighting white blood cells become trapped and die. Pus forms and an abscess develops. Abscesses can destroy both gum and tooth tissue, cause nearby teeth to become loose and painful, and may cause fever and swollen lymph nodes.

Pain is usually not a symptom, which partly explains why the disease may become advanced before treatment is sought and why some patients avoid treatment even after periodontitis is diagnosed.

WHAT CAUSES PERIODONTAL DISEASE?

Periodontal disease is marked by inflammatory injuries (called lesions) from calculus, a hard substance that forms from plaque, which is essentially bacterial overgrowth.

Bacterial Culprits

In the healthy mouth, more than 350 species of microorganisms have been found. Periodontal infections are linked to fewer than 5% of these species. Healthy and disease-causing bacteria can generally be grouped into two categories:

The harmless or helpful bacteria are usually known as gram positive aerobic bacteria .
In periodontal disease, the bacterial balance shifts over to gram negative anaerobic bacteria . Inflammatory disease and injury cannot develop without these bacteria.

Among the bacteria most implicated in periodontal disease and bone loss are the following:

Actinobacillus (A.) actinomycetemcomitans and Porphyromonas (P.) gingivalis. These two bacteria appear to be particularly likely to cause aggressive periodontal disease. In one study, both P. gingivalis and A. actinomycetemcomitans, along with multiple deep pockets in the gum, were associated with resistance to standard treatments for gum disease. In another study, P. gingivalis doubled the risk for serious gum disease. Particularly virulent strains of this bacteria may be responsible for periodontal disease. A 2001 study suggests that the P. gingivalis produces enzymes, such as one called arginine-specific cysteine proteinase, which may be the specific destructive factors that disrupt the immune system and lead to subsequent periodontal connective tissue destruction.
Bacteroides (B.) forsythus is also strongly linked to periodontal disease.
Other bacteria associated with periodontal disease are T. denticola, T. sokranskii and P. intermedia . These bacter, together with P. gingivalis , are frequently are present at the same sites, and are associated with deep periodontal pockets.

Some bacteria are related to gingivitis, but not plaque development. They include various streptococcal species.

The Autoimmune and Inflammatory Response

Evidence now suggests that periodontal disease may be an autoimmune disorder , in which immune factors in the body attack the person's own cells and tissue--in this case, those in the gum. It appears to work as follows:

The bacteria that form plaque and tartar release toxins that stimulate the immune system to over produce powerful infection-fighting factors called cytokines.
Ordinarily, cytokines are important for healing. In excess, however, they can cause inflammation and severe damage.
Cytokines of particular importance in periodontal disease are known as tumor necrosis factor-alpha (TNF-alpha) and interleukin interleukin-1beta and interleukin 4 (IL-1 and IL4), which are very active in the mouth.
In excess, these cytokines overproduce an enzyme called collagenase, which breaks down proteins, including the connective tissue that holds teeth in place.

Studies suggest that this inflammatory response may have damaging effects not only in the gums but also in organs throughout the body, include the heart. [See How Serious is Periodontal Disease?]

Viral Causes

Certain herpesviruses (herpes simplex and varicella-zoster virus, the cause of chicken pox and shingles) are known causes of gingivitis. A 2000 study found that other herpes viruses (cytomegalovirus and Epstein-Barr) may play a role in the onset or progression of some types of periodontal disease, including aggressive and severe chronic periodontal disease. All herpes viruses go through an active phase followed by a latent phase and possibly reactivation.

Some experts hypothesize that these viruses may cause periodontal disease in different ways, including release of tissue-destructive cytokines, overgrowth of periodontal bacteria, suppressing immune factors, and initiation of other disease processes that lead to cell death.

WHO GETS PERIODONTAL DISEASE?

Although many conditions cause gum inflammation and ulcers, not all people develop periodontal disease. Certain factors put individuals at higher risk than others.

Abnormal Oral Environment

Lack of Oral Hygiene. Lack of oral hygiene encourages bacterial build-up and plaque formation.

Sugar and Acid. The bacteria that cause periodontal disease thrive in acidic environments. Therefore, eating sugars and other foods that increase the acidity in the mouth increase bacterial counts.

Poorly Contoured Restorations. Poorly contoured restorations (fillings or crowns) that provide traps for debris and plaque can also contribute to its formation.

Anatomical tooth abnormalities. Abnormal tooth structure can increase the risk.

Age

Children and Adolescents. Gingivitis, in varying degrees, is nearly a universal finding in children and adolescents. In rare genetic cases, children and adolescents are subject to destructive forms of the disease. Researchers have also observed some of the organisms seen in periodontal disease in young children without signs of gum problems. Healthy children, however, do not, generally harbor two primary periodontal bacteria, P. gingivalis and T. denticola .

The disease is also uncommon in teenagers. According to one survey, only 1% of 14 to 17 year olds have any sign of actual periodontal disease.

Adults. One survey reported that 3.6% of adults between the ages 18 and 34 had periodontal disease. A 2000 New Zealand study, however, reported that one in seven 26 year olds (about 14%) had signs of well-established periodontal disease. (It should be noted that populations may differ in their risk.) As people age, the risk for peridontal disease increases. Over half of American adults have gingivitis surrounding three to four teeth and 30% have significant periodontal disease surrounding an average of three to four teeth. In a study of people over 70 years old, 86% had at least moderate periodontitis and over a quarter of them have lost their teeth.

Female Hormones

About three-quarters of periodontal office visits are made by women, even though women tend to take better care of their teeth then men do. Female hormones affect the gums, and women are particularly susceptible to periodontal problems.

Before Menstruation. Gingivitis may flare up in some women a few days before they menstruate when progesterone levels are high. Progesterone dilates blood vessels causing inflammation, and blocks the repair of collagen, the structural protein that supports the gums.

Pregnancy. Hormone-influenced gingivitis appears in some adolescents, in some pregnant women, and is occasionally a side effect of birth control medication. During pregnancy gum inflammation typically develops around the second month and reaches a peak in the eighth month. It usually resolves after delivery. (It should be noted that existing periodontal disease in pregnant women may actually have some harmful effects.) [ See Pregnancy under How Serious is Periodontal Disease?]

Oral Contraceptives. One study reported that taking oral contraceptives containing the synthetic progesterone desogestrel (but not dienogest, another common progesterone) increased the risk for periodontal disease.

Menopause. During menopause, some women may develop a rare condition called menopausal gingivostomatitis, in which the gums are dry, shiny, and bleed easily. At that time, women may experience abnormal tastes and sensations (eg, salty, spicy, acidic, burning) in the mouth. Osteoporosis is related to estrogen loss after menopause and is also associated with bone loss. [ See Osteoporosis below.]

Family Factors

Periodontal disease often occurs in members of the same family. Genetics, intimacy, hygiene, or a mixture of factors may be responsible. Studies have found that children of parents with periodontitis were 12 times more likely to have the bacteria thought to be responsible for causing plaque and, eventually, periodontal disease.

Genetic Factors. According to a 2000 study, not environment or poor hygiene, but genetic factors may play the critical role in half the cases of periodontal disease. Up to 30% of the population may have some genetic susceptibility to periodontal disease. For example, some people with severe periodontal disease have genetic factors that affect an immune factor known as interleukin-1 (IL-1), a cytokine involved in the inflammatory response. Such individuals are up to 20 times more likely to develop advanced periodontitis than those without such genes. Early onset and rapidly progressive periodontal disease also have strong genetic components.

Intimacy. Intimate partners and spouses of people with periodontal disease may also be at risk. Researchers have found that the bacteria P gingivalis may be contagious after exposure to an infected person over a long period of time. There is no risk from short exposure, such as after a fast kiss or when sharing an eating utensil.

Smoking

Smoking is the single major preventable risk factor for peridontal disease, and can cause bone loss and gum recession even in the absence of periodontal disease. A number of studies indicate that smoking and nicotine increase inflammation by reducing oxygen in gum tissue and triggering an over-production of immune factors called cytokines (specifically ones called interleukins), which in excess are harmful to cells and tissue.

Furthermore, when nicotine combines with oral bacteria, such as P. gingivalis , the effect produces even greater levels of cytokines and eventually leads to periodontal connective tissue breakdown. Studies suggest that smokers are 11 times more likely than nonsmokers to harbor the bacteria that cause periodontal disease and four times more likely to have advanced periodontal disease. In one study over 40% of smokers lost their teeth by the end of their lives.

The risk of periodontal disease increases with the number of cigarettes smoked per day. Smoking cigars and pipes carries the same risks as smoking cigarettes. Exposure to second-hand smoke is also associated with a 50% to 60% increased risk for developing periodontal disease, according to a 2001 study. Fortunately, when smokers quit, their periodontal health gradually recovers to a state comparable to that of nonsmokers.

Diseases Associated with Periodontal Disease

Diabetes. Much evidence exists on the link between diabetes type 1 and 2 and periodontal disease. People with these diseases have 15 times the risk of the nondiabetic population. Diabetes causes abnormalities in blood vessels and high levels of specific inflammatory chemicals, such as interleukins, that significantly increase the chances of periodontal disease. High levels of triglycerides (which are common in type 2 diabetes) appear to impair periodontal health. A high blood sugar level, which is the hallmark of diabetes, has even been associated with severe periodontal disease in people without diabetes, according to a 2000 study. Obesity, which is common in type 2 diabetes, may also predispose a person to gum disease. Studies in 1999 and 2000 suggest controlling both type 1 and 2 diabetes may also help reduce periodontal problems.

Osteoporosis. Osteoporosis (loss of bone density) has been associated with periodontal disease in postmenopausal women. There is some evidence that some treatments for osteoporosis, such as bisphosphonates, may reduce bone loss, including the bony structures that support the teeth.

Herpes-Related Gingivitis. Herpes virus is a common cause of gingivitis in children and has become increasingly common in adults. It typically starts out with a purplish color and "boggy" sensation in the gums (especially inside). Multiple blisters may form across the mucus membranes in the mouth and gums, followed by ulcers. They usually resolve in seven to 14 days.

HIV-Associated Gingivitis. HIV-associated gingivitis has been reported in 15% to 50% of patients with AIDS. HIV positive individuals harbor larger numbers of periodontal bacteria (candida albicans, P. gingivalis, black-pigmented anaerobic rods, and A. actinomycetemcomitans) than people without HIV. Severe pain is characteristic, along with odor, spontaneous bleeding, ulcers, and swollen, bright red gums. The inflammation never recedes, but halitosis and acute episodes can be managed by conventional cleaning treatments. Its severest form, known as necrotizing stomatitis, can be diagnostic for AIDS; in addition to bleeding, the gums in the front of the mouth are a yellowish-gray color, and bone thrusts out.

Other Diseases. Autoimmune conditions (eg, Crohn's disease, rheumatoid arthritis, lupus erythematosus, CREST syndrome) have been associated with a higher incidence of periodontal disease. Other diseases associated with periodontitis include leukemia and other cancers, tuberculosis, syphilis, Wegener's granulomatosis, amyloidosis, and many genetic disorders.

Vitamin C Deficiencies

Vitamin C helps the body repair and maintain connective tissue, and its antioxidant effects are important in the presence of tissue-destroying oxidants in periodontal disease. A large 2000 study found that people who consumed less than the recommended daily allowance of vitamin C, 60 mg (about one orange), were one and a half times more likely to develop severe gingivitis than those who consumed more than 180 mg of vitamin C per day. (It should be noted that smoking also depletes vitamin C supplies.)

Ethnic, Socioeconomic, and Geographic Factors

Dental disease is most likely to affect the poor. Children and the elderly suffer the worst oral care, and ethnic minorities follow. A 2002 study reported that the amount of oral bacteria was greater in people who visited their dentist least and when educational levels were low. Ethnicity played no role. It is distressing enough that 44 million Americans lack medical insurance, but almost two and a half times that number (108 million Americans) lack dental insurance. In one survey in five states (Arizona, California, Hawaii, Oregon, and Wisconsin), the rate of total tooth loss was less than 20%, while in three states (Kentucky, Louisiana, and West Virginia) it was greater than 40%.

Drug-Induced Gingivitis

Gingival overgrowth can be a side effect of nearly twenty different drugs, most commonly phenytoin (Dilantin), cyclosporine (Sandimmune), and a short-acting form of the calcium channel blocker nifedipine (Procardia).

Other Causes of Gum Inflammation

A number of other conditions can also cause gum inflammation, and some have been associated with periodontal disease. They include the following:

Mouth breathing.
Psychologic stress. A review of studies in 2000 that investigated the association between psychological stress and periodontal disease confirmed the impact of stress on the immune system. Thus, stress can probably influence chronic inflammatory diseases, like periodontitis. Psychological stress should therefore be assessed before and during treatment. As of yet, however, there is no definite proof of that stress leads to periodontal disease.
Canker sores (aphthous ulcers).
Self-injury in psychologically disturbed patients.
Hereditary gingival fibromatosis. A rare genetic disease associated with both gum overgrowth and hairiness. It is often associated with gingivitis and periodontal disease.
Desquamative gingivitis. With this condition the outer layer of the gum tissue desquamates (peels away), exposing an acutely red surface. It usually occurs as a result of an allergic reaction or of skin diseases such as lichen planus, benign mucous membrane pemphigoid, bullous pemphigoid, and pemphigus vulgaris (although one study also suggested that bacteria may play role in this gum disease as it does in more common forms). This condition generally resolves when the allergic reaction or skin disease is treated and clears up. It is fairly common in middle-aged women.

HOW SERIOUS IS PERIODONTAL DISEASE?

Tooth Loss

The ultimate outcome of uncontrolled periodontal disease is tooth loss. As the destructive factors cause the breakdown of bone and connective tissue, there remains no anchor for the teeth.

Bad Breath

A much less severe but nevertheless distressing problem caused by periodontal disease is bad breath, although coatings on the tongue may contribute more to bad breath than even periodontal disease.

Heart Disease and Stroke

Some studies have reported a one and a half- to four-fold increased risk for heart disease in people with periodontal disease. (The four-fold risk was in men with extensive gum disease, bleeding from every tooth.) In one study, 85% of heart attack patients had periodontal disease compared to 29% of people with no heart problems. Periodontal disease has also been associated with stroke. In addition, high cholesterol blood levels have been associated with both chronic periodontal disease and coronary artery disease.

Recent evidence is pointing to the inflammatory response as the common element. This is an over-reaction of the immune system that causes injury to tissues in the body. A common link between patients with both heart conditions and periodontal disease may be elevated levels of C-reactive protein (CRP), a marker for the inflammatory response. Some experts believe, then, that immune factors causing this response are released into the blood stream during periodontal disease and cause injury in the arteries supplying blood to the heart. Other evidence suggests that the bacteria itself, particularly P. gingivalis, may play a direct role in arterial injury.

Treating and eliminating periodontitis does not appear to have any effect on preventing heart disease, however. Some experts believe that there is no actual causal relationship, but that common factors induce inflammation and damage resulting in diseases in the blood vessels and in the gums. Studies in 2000 and 2001 suggest that the only significant association between periodontal disease and heart disease is a socioeconomic one. In the 2000 study, for example, patients who had both conditions were more likely to be poor, African American, older, and overweight. They were also more likely to have other risk factors for heart disease, including smoking and diabetes.

Effect on Diabetes

Diabetes is not only a risk factor for periodontal disease, but periodontal disease may exacerbate or even cause diabetes. Some evidence has suggested that the bacteria causing periodontal disease may enter the blood stream and activate cytokines, the damaging factors in the immune system, which then may even destroy cells in the pancreas, where insulin is produced. One study found that treating periodontal disease reduced the need for insulin in some people with diabetes.

Effect on Respiratory Disease

Bacteria that reproduce in the mouth can also be carried into the airways of throat and lungs, increasing the risks for respiratory diseases and worsening chronic lung conditions, such as emphysema.

Effect on Pregnancy

The bacterial infections that cause moderate to severe periodontal disease in pregnant women may also increase the risk of premature delivery and low birth weight infants. Research indicates that the bacteria from periodontal disease may trigger the same factors in the immune system as genital and urinary tract infections do. These biologic substances called prostaglandins and tumor necrosis factor produce inflammation in the cervix and uterus that can cause premature dilation and contractions. Some experts recommend that women have a periodontal examination before becoming pregnant or as soon as possible thereafter. Because women with diabetes are at higher risk for periodontal disease, it is particularly important for diabetics to see a dentist early in pregnancy.

HOW CAN PERIODONTAL DISEASE BE PREVENTED?

Healthy habits and good oral hygiene are critical in preventing gum disease. Regular and effective tooth brushing and mouth washing, however, are effective only above and slightly below the gum line. Once periodontal disease develops more intensive treatments are needed.

Dietary Changes

It is important to reduce both the quantity, and in particular the frequency, of sugar intake. Snacks and drinks should be free of sugars (other than natural sugars found in fruits and vegetables); sugar-containing foods should be consumed with meals and ideally followed by brushing. Since fruit juices can also cause tooth erosion in children, milk and water use should be emphasized.

Quitting Smoking

Smoking may play a significant role in over half the cases of chronic periodontal disease, according to research published in 2000. For smokers, quitting is one of the most important steps toward regaining periodontal health.

Fluoride Treatments

Fluoride treatment in children has helped to account for the decline in periodontal disease in adults. Because fluoride prevents decay, back molars, which keep the teeth in place, are spared, and are thus less vulnerable to bacteria. Even before teeth first erupt, babies' gums should be wiped clean with a bit of gauze bearing a dab of fluoride toothpaste. Supplementation with fluoride tablets or drops may be recommended for children 6 months or older who drink unfluoridated water or who are at risk for dental problems. A prescription from the child's pediatrician or dentist is required.

Some dentists recommend a fluoride gel for adult patients who are still at risk for tooth decay or sensitivity, but extra fluoride is generally not necessary for adults who use fluoride toothpaste.

Dental Examinations

Periodontitis is a silent disease; individuals rarely experience pain and may not be aware of the problem. A periodontal examination by a general dentist once or twice a year should reveal any incipient or progressive problems. A full mouth series of x-rays is advised every two to three years. This will alert the dentist to early bone loss and other disorders of the oral cavity.

Dentists now often perform Periodontal Screening and Recording (PSR) using a probe to measure gum pockets. This procedure used to be performed only by periodontists but is now encouraged as part of a regular dental examination. The dentist will identify any areas where deep pocketing has occurred, where the health of the gingiva appears compromised, and where there is undue mobility of teeth. It is the general dentist's responsibility to identify periodontal disease and inform the patient. If the condition is severe, the dentist may want to refer the patient to a periodontist. [ See What Will Confirm a Diagnosis of Periodontal Disease?, in this report. ]

Daily Dental Care

Correct tooth brushing, mouth cleansing, and flossing should be everyone's defense against periodontal disease.

Brushing Guidelines. The following are some recommendations for brushing:

First use a dry brush. One study reported that when people brushed their teeth without toothpaste first, using a soft dry brush, their plaque deposits were reduced by 67% and gum bleeding dropped by 50%.
No brush of any size, shape, or gimmick is effective if it is incorrectly positioned in the mouth. Place the brush where the gum meets the tooth, with bristles resting along each tooth at a 45-degree angle.
Begin by dry brushing the inside the bottom row of teeth, then the inner top teeth, and last the outer surfaces.
Wiggle the brush back and forth so the bristles extend under the gum line.
Scrub the broad, biting surfaces of the back teeth.
Dry brushing should take about a minute and a half.
A paste is then applied and the teeth should be rebrushed in the same way.
The tongue should be scrubbed for a total of about 30 seconds. A tongue scraper used with an anti-bacterial mouthwash (such as Listerine) is more effective than a toothbrush in removing bacteria.
One should rinse the toothbrush thoroughly and then tap it on the edge of the sink at least five times to get rid of debris. (It should be noted that detergents in toothpaste that remain on the brush may help prevent bacterial contamination of the brush.)
Flossing should finish the process. A mouthwash may also be used. [For these processes, see below.]

If brushing after each meal is not possible, rinsing the mouth with water after eating can reduce bacteria by 30%.

Toothbrushes. A vast assortment of brushes of varying sizes and shapes are available, and each manufacturer makes its claim for the benefits of a particular brush. Toothbrushes should be replaced every month. Not only do they become breeding grounds for bacteria, but the worn bristles are less effective at removing plaque.

People should look for the American Dental Association (ADA) seal on both electric and regular brushes.

For individuals with average dexterity, a four- or five-rowed, soft, nylon-bristled toothbrush is sufficient.

Electric toothbrushes, particularly those with a stationary grip and revolving tufts of bristles, can be advantageous for some people with physical disabilities. They include the following:

Electric toothbrushes with heads that move back and forth up to 4,200 times a minute remove significantly more plaque than ordinary brushes. Brands are Bausch & Lomb's Interplak, Braun's Oral-B Plaque Remover, and Water Pik's Plaque Control.
Even more high-tech brushes are now available that use sound waves to remove plaque. Brands include Sonicare, SenSonic, Soniplak, and UltraSonex. One study showed considerable improvement in groups using sonic toothbrushes, particularly in those with moderate periodontal disease.

Experts recommend, however, that if a regular toothbrush works, then it isn't necessary to buy an expensive electric one.

The most important factor in buying any toothbrush, electric or manual, is to choose one with a soft head. Soft bristles get into crevices easier and do not irritate the gums. One study found that those who used a soft toothbrush had 4.7% of exposed tooth below the gum line compared to 9.4% with hard brush users. A useful toothbrush called Alert has been developed that flashes a red light when too much pressure is being placed on the gums.

Toothpaste. The object of a good toothpaste is to reduce the development of plaque and eliminate periodontal causing microorganisms without destroying the organisms that are important for a healthy mouth. All brands should show ADA approval. Even a good toothpaste, however, cannot be delivered past 3 millimeters below the gum line, where periodontitis develops.

Toothpastes are a combination of abrasives, binders, colors, detergents, flavors, fluoride, humectants, preservatives, and artificial sweeteners. Highly abrasive toothpastes should not be used, especially by individuals whose gums have receded.

Active agents contained in toothpastes may include the following:

Fluoride. Most commercial toothpastes contain fluoride, which both strengthens tooth enamel against decay and enhances remineralization of the enamel. Fluoride also inhibits acid-loving bacteria, especially after eating, when the mouth is more acidic. Some argue that this antibacterial activity may help control plaque.
Triclosan. Colgate's Total toothpastes contain both fluoride and triclosan. Total is the first FDA approved toothpaste for the prevention of tooth decay, gingivitis, and plaque. Triclosan remains in the mouth after use and is an extremely potent anti-bacterial agent. Of some concern, however, are studies reporting development of bacteria resistant to triclosan. More studies are needed.
Metal salts. Metal salts, such as stannous and zinc, serve mostly as anti-bacterial agents in toothpastes. Stannous fluoride gel toothpastes do not reduce plaque, however, even though they have some effect against the bacteria that cause it, but slightly reduce gingivitis. Such toothpastes can cause staining that requires professional cleaning. Crest Plus Gum Care contains a stabilized form of stannous fluoride. Studies conducted by the manufacturer suggest that is has antibacterial activity and that it might be more effective than Colgate's Total in reducing gingivitis and bleeding.
Enzymes called glucanases.
Plant extracts (such as sanguinarine). Viadent toothpaste and mouthwash contain an anti-bacterial herbal extract called sanguinarine. The two products provide minimal results when used individually, but if the mouthwash and toothpaste are used together they have produced plaque reductions of 17% to 42% and reductions of gingivitis of 18% to 57% during a six-month period. It should be noted that some questions have been raised about the safety of prolonged use of sanguinarine.
Peroxide and baking soda. Toothpastes with these ingredients (Mentadent) appear to offer no benefits against gum disease. In fact, tooth whiteners are usually made with carbamide peroxide, which breaks down into hydrogen peroxide, and brushing with hydrogen peroxide is not recommended. Studies have indicated that overuse of this solution may actually damage cells and soften tooth surfaces. Of concern was a recent animal study suggesting a link between hydrogen peroxide and precancerous cell changes in the mouth. Researchers retracted the findings because of these implications and pointed out that no cancer lesions have developed in any animals since the study began. People who smoke or drink alcohol, however, might avoid products with hydrogen peroxide in them.
Antibacterial sugar substitutes (eg, xylitol), and detergents (delmopinal).

Mouthwashes. The value of many mouthwashes is highly controversial. Many have only temporary antibacterial value. Some can even harm the mucus membrane and they can be dangerous to children who drink them. Those that are considered plaque fighters are chlorhexidine and Listerine, which is available over the counter.

Chlorhexidine (Peridex or PerioGard) is available by prescription only. It reduces plaque by 55% and gingivitis by 30% to 45%. Patients should rinse for one minute twice daily. They should wait at least 30 minutes between brushing and rinsing since chlorhexidine can be inactivated by certain compounds in toothpastes. It has a bitter taste. It also binds to tannins, which are in tea, coffee, and red wine, so it has tendency to stain teeth in people who drink these beverages.
Listerine is composed of essential oils and is available over the counter. It reduces plaque and gingivitis, when used for 30 seconds twice a day. It leaves a burning sensation in the mouth that most people better tolerate after a few days of use. Some people might object to or have concerns about the high alcohol content in the standard version. Other forms of Listerine that have a different taste and lower alcohol content retain the same active ingredients and appear to be as effective. The usual regimen is to rinse twice a day. Generic equivalents are available.
Mouthwashes containing cetylpyridinium (Scope, Cepacol) and stannous fluoride and amine fluoride (Meridol) have some effect on plaque. None are as effective as Listerine or chlorhexidine, but they may still have some value for people who cannot tolerate the other mouthwashes.
In spite of claims for Plax, some studies report that Plax offers no better protection against plaque or periodontal disease than does rinsing with water. Even Advanced Formula Plax, which may show a minor reduction in plaque levels, does not seem to provide any protection against periodontal disease.

Some chemicals are being investigated for their use in mouthwashes. For example, one mouthwash (HistaWash) is produced from histatins, peptides found in saliva. Studies are reporting that it protect against gum disease and prevents other infections in the mouth as well.

Flossing. In spite of the importance of flossing, only 2% to 10% of the population perform this technique regularly.

The use of dental floss, either waxed or unwaxed, is critical in cleaning between the teeth where the toothbrush bristles cannot reach. In spite of this, nearly two-thirds of people do not floss.

To floss correctly, the following steps may be helpful:

Break off about 18 inches of floss and wind most of it around the middle finger of one hand and the rest around the other middle finger.
Hold the floss between the thumbs and forefingers and gently guide and rub it back and forth between the teeth.
When it reaches the gum line, the floss should be curved around each tooth and slid gently back and forth against the gum.
Finally, rub gently up and down against the tooth. Repeat with each tooth, including the outside of the back teeth.
If, on repeated flossing attempts, the floss becomes shredded or cannot be removed easily from between the teeth, a rough crown or overhanging filling may be the cause. In such cases, the restoration should be redone. Such areas create spaces for the collection of food debris, plaque, and calculus.

Here are some tips in choosing the right floss or flossing device:

Use a floss that does not shred or break.
Avoid a very thin floss, which can cut the gum if brought down with too much force or not guided along the side of the tooth.
People who have very tight spaces between their teeth should consider flosses that are made of Gore-Tex. This floss slips easily between tight teeth and will not tear on sharp edges. It does cost slightly more, however.
A floss threader is an invaluable aid for the person who has bridgework. Made of plastic, it looks like a needle with a huge eye, or loop. A piece of floss is threaded into the loop, which can then be inserted between the bridge and the gum. The floss that is carried through with it can then be used to clean underneath the false tooth or teeth and along the sides of the abutting teeth.
Another handy device for cleaning under bridges is a Proxabrush. This is a tiny narrow brush that can be worked in between the natural teeth and around the attached false tooth or teeth.
The Floss Plus easy flosser device is also effective and may make it easier for some people to floss.
Special toothpicks, such as Stim-U-Dent, may be effective for wide spaces between teeth but should never replace flossing. Standard toothpicks should never be used for regular hygiene.
Electronic products, such as Oral B Innerclean and the Water Pik Flosser are as effective as manual flossing. These devices are expensive but may improve compliance.

Producing Saliva and Drinking Water. Saliva is important for diluting the toxins created by plaque. Of particular interest is a 2000 study on nitrite, a substance in saliva whose concentration increased after eating foods containing nitrates. Nitrite converts to the gas nitric oxide (NO), which, under acidic conditions, may prevent the growth and survival of bacteria involved in periodontal disease.

Drinking at least seven glasses of water a day helps reduce inflammation in the mouth by producing more saliva. Increasing water intake is particularly important as one ages, when less saliva is produced.

Food Chemicals and Supplements

Vitamins E and A. One study showed that women with diabetes who took vitamins E and A during pregnancy had reduced incidence of periodontal inflammation. Vitamins are not recommended for prevention of periodontal disease, however. Vitamin A is toxic in high doses, and this study was too narrow to extrapolate for the general population. It is an interesting finding, however, because of its potential for more research in this area.

Coenzyme Q-10. Coenzyme Q-10 (CoQ10), also called ubiquinone is a vitamin-like antioxidant compound that occurs naturally in the body and plays a role in energy production. Research shows that the gums of people with periodontal disease are often significantly deficient in CoQ10, and some evidence suggests that topical or oral CoQ10 may be effective in slowing the disease process. There is no strong proof, however, and more research is needed.

Food Extracts. A 2001 study found that avocado and certain soy extracts prevented the damaging effects of interleukins, immune factors responsible for inflammation and injury during periodontal disease.

Hormone Replacement Therapy

Research suggests that postmenopausal women who take hormone replacement therapy (HRT) experience fewer periodontal problems. Studies indicate that estrogen reduces gum bleeding and bone loss. (HRT is very effective in preventing osteoporosis, a condition in which bone loss occurs and which is strongly linked with peridontal disease.) HRT has some risks, as well, and women should discuss this treatment thoroughly with their physician.) [For more information see report # 40 Menopause, Estrogen Loss and Their Treatments.]

WHAT WILL CONFIRM THE DIAGNOSIS OF PERIODONTAL DISEASE?

The dental practitioner typically performs a number of procedures to determine a diagnosis of periodontal disease.

Medical History

The practitioner will first take a medical history to reveal any past or present periodontal problems, any underlying diseases that might be contributing to the problem, and any medications the patient is taking. After noting the general state of oral hygiene, the practitioner may ask about the quality of home dental care.

Physical Examination

Inspection of the Gum Area. The practitioner inspects the color and shape of gingival tissue on the cheek (buccal) side and the tongue (lingual) side of every tooth and compares these qualities to the healthy ideal. Redness, puffiness, and bleeding upon probing indicate inflammation. If the gum formation between teeth is blunt and not pointed, acute necrotizing periodontal disease may be indicated.

Periodontal Screening and Recording (PSR). PSR is a painless procedure used to measure and determine the severity of peridontal disease:

The practitioner uses a mirror and a periodontal probe, a fine instrument calibrated in millimeters, which is used to measure pocket depth. (A new automatic probing device may prove to be even more sensitive and accurate than the standard manual probe that most dentists use.)
The probe is held along the length of the tooth with the tip placed in the pocket. The tip of the probe will then touch the point where the connective tissue attaches to the tooth.
The dentist will "walk" the probe to six specified points on each tooth, three on the buccal (cheek) and three on the lingual (tongue) sides. The dentist measures the depth of the probe at each point.
Pocket depths greater than 3 millimeters indicate disease.

These measurements enable the practitioner to determine the condition of the connective tissue and amount of gingival overgrowth or recession. PSR appears to be even more reliable than x-rays in diagnosing gum disease.

Testing Tooth Movement. Tooth mobility is determined by pushing each tooth between two instrument handles and observing any movement. Mobility is a strong indicator of bone support loss.

X-rays. X-rays are taken to show any loss of bone structure supporting the teeth. Eighteen x-rays make up the full mouth series necessary for diagnosis.

WHAT ARE THE PROCEDURES FOR TREATMENT OF PERIODONTAL DISEASE?

General Guidelines

Treatment Goals. Once periodontal disease has been identified, the goals of treatment are the following:

To arrest and control the progress of the disease.
To leave the periodontal tissues in an easily maintainable state.
If possible, to restore the supporting structures, which include bone, gum tissue, and ligaments.

Treatment Phases. To achieve these goals, there are three phases of professional periodontal treatment:

Initial Cleaning, Scaling, and Curettage.
Surgery (if needed). Surgery is indicated when deep pockets remain underneath the gum after extensive cleaning sessions. The depth of these pockets must be reduced.
Maintenance. After the active treatment is completed and the mouth is in a relative state of health, the patient should have regular cleanings lasting 45 minutes to an hour, approximately every three months. These may be done by the dental hygienist, the periodontist, or the general dentist. They patient may alternate between them. Home care, of course, must be continued. [ See How Is Periodontal Disease Prevented, above.]

Antibiotics before Treatment. In cases where the individual has a mitral valve prolapse or history of rheumatic heart disease, pretreatment with an appropriate antibiotic is required before any dental work, including cleaning. This is necessary to prevent the possibility of bacterial endocarditis, which can be life threatening.

Benefits of Treatment. Studies vary over the effectiveness of active treatments and maintenance programs. While a study of elderly Chinese adults found no difference in tooth loss between those who had access to health care compared to those who didn't, another study reported that those who had active maintenance were much less likely to lose their teeth than those who did not. Some dentists have reported a success rate of 85% when professional treatment and good home maintenance are combined.

Treatment helps nonsmokers more than smokers, particularly when pockets are deep and persistent. One study found that periodontal treatment in people with diabetes type II actually helped improve blood sugar levels. Whether treatment will help reduce other health risks, including heart attack and stroke, is unknown.

Cleaning, Scaling, and Curettage

Scaling, polishing, and sometimes curettage are used to manage periodontal disease. They are usually accomplished in a series of three to four visits spaced about a week apart.

Cleaning and Scaling. The dental hygienist or practitioner generally uses both ultrasonic and manual instruments to remove calculus.

Calculus above the gum is easily seen. The dental professional usually detects calculus below the gum by careful probing with a dental instrument.
The hygienist or dentist may use an ultrasonic instrument for removal of the more accessible calculus. This probelike device vibrates at a frequency range higher than is audible to the human ear. Some people with low tolerance for the ultrasonic probe may wish to request nitrous oxide.
A spray of water is used with ultrasound to prevent overheating and to flush out the debris that is dislodged.
When the probe contacts the rock-like calculus, deposits fracture off the tooth fairly efficiently.
Povidone-iodine (PVP-I), a potent antiseptic, can reduce the level of gingivitis and may be more beneficial than water as the irrigant used during ultrasonic treatment. Further studies are needed.

Curettage. Curettage removes the diseased soft tissue lining the periodontal pockets. It is a manual procedure and permits a deeper and more complete cleaning than ultrasound. It does not add any significant benefits for shallow pockets. Local anesthesia is often used. Fine scaling instruments, called curettes, serve two functions:

They scrape and clean the root surfaces.
They also plane the surfaces in an attempt to smooth and remove the outer layer of diseased material.

Repeated scaling and root planing with steel instruments may cause loss of the tooth surface and increased sensitivity of the teeth over time. Newer plastic instruments may be just as effective without damaging the hard structure of the tooth.

Polishing. Polishing is the finishing procedure. It employs a rubber cup with an abrasive paste to remove plaque and stains on the crown portion of the tooth. It produces a smooth surface, making it harder for plaque to adhere. Its benefits are short lived, however.

Instructions for Home Care. Finally, the dental hygienist or practitioner should offer thorough instructions on home care to insure the removal of bacteria on a daily basis. This includes proper use of the toothbrush, paste, mouth rinses, floss, floss threaders, and proxabrushes. Home care can effectively eliminate the plaque above the gums and down to 2 mm below the gums.

Follow-Up. The dentist will check the pocket depths around the teeth after the cleaning and curettage process has been completed. Further treatment needs are determined by the results of these initial sessions:

If the cleaning processes have reduced inflammation, observation only is needed.
If an abscess is present, surgery is often warranted. (One case study suggested that simply draining an abscess caused by deep pockets and allowing the periodontal pockets to improve and the gum tissue to return to health may avoid the need for surgery. If, in such cases, tissue health has not been achieved, and if the pocket depth is greater than 4 mm, surgery may be necessary.)

Surgery

Surgery allows access for deep cleaning of the root surface, removal of diseased tissue, and repositioning and shaping of the bones, gum, and tissues supporting the teeth. (Some studies have reported that although surgical treatment reduced pocket depth more than non-surgical therapies for at least one year after the procedure, benefits from surgery do not persist beyond five years, except in very deep pockets.) Surgical procedures vary depending on the individual diagnosis and needs of the patient.

Open Flap Curettage . The basic procedure is known as open flap curettage. It involves the following:

The periodontal surgeon lifts, or flaps, the gums away from the tooth and surrounding bone.
The diseased root surfaces are cleaned and curetted (scraped) to remove deposits.
Gum tissue is replaced into positions to minimize pocket depth.
The periodontist may also contour the remaining bone and attempt to regenerate lost bone and gingival attachment through bone grafts and guided tissue regeneration [ see below ].

Guided-Tissue Regeneration. A more advanced technique is called guided tissue regeneration, which is being used to stimulate bone and gum tissue growth:

First the root surfaces and diseased bone are meticulously cleaned out. Preventing bacterial contamination is very important; the more residual bacteria, the greater the chance that the treatment will fail.
A specialized piece of fabric is sewn around the tooth to cover the crater in the bone left after the cleaning. It is either absorbable or nonabsorbable. (Studies are reporting highly beneficial results with new absorbable materials, including one that is coated with the antibiotic doxycycline.)
The gum is then sewn over the fabric. The fabric prevents the gum tissue from growing down into the bone defect and allows the bone and the attachment to the root to regenerate.
After four to six weeks the nonabsorbable fabric must be removed using a minor surgical procedure. The absorbable membrane may be left in. In general, there is little difference in outcome between absorbable and nonabsorbable procedures. The absorbable fabric may not be as effective as standard grafts if gum tissue is thin, although newer materials may prove to produce better results.

One 1999 study found that guided tissue regeneration techniques surpassed open flap curettage alone in improving pocket depth and attachment gain. In one study of patients who were followed for four to seven years after guided tissue regeneration, the general failure rate was 41%. In smokers, however, the failure rate was 80%.

Bone Grafting. In some cases of severe bone loss, the surgeon may attempt to encourage regrowth and restoration of bone tissue that has been lost through the disease process. This involves bone grafting:

The surgeon places bone graft material into the defect.
The material may be either bone from the same patient or a substance called decalcified freeze-dried bone allografts (DFDBA) which is obtained from a donor. In one study, bone gain from freeze-dried bone was still maintained after three years, although another study indicated that commercial batches of DFDBA varied in their ability to induce new bone growth. Bone from older donors appears to be less effective for restoring new bone.
This material then stimulates new bone growth in the area.

Postsurgery Pain and Discomfort. Post-surgery discomfort is usually managed easily with over-the-counter medications, such as ibuprofen. If discomfort is severe, stronger analgesics may be prescribed. Some patients experience sensitivity to hot or cold temperatures from exposed roots; these problems can be managed with topical fluoride treatments or, in severe cases, with dental restoration.

Cosmetic and Gum Grafting Treatments

Gum grafting techniques can also be very useful for improving the looks of the gum as well as adding support to the teeth. During this procedure, the periodontist takes gum tissue from the palate or another donor source to cover the exposed root in order to even the gum line and reduce sensitivity. Other procedures are available to improve the look of the gums and teeth. The gum line can be sculpted to improve uneven or excess gums and to cover exposed roots as gums recede.

Implants

Periodontists report that they are achieving greater success with tooth implants in patients who have lost teeth due to periodontal disease. The average cost for a single implant is high, however, $1,000 to $2,000, and one implant requires five to seven months for completion.

Note on Laser Surgery

The American Academy of Periodontology is concerned with misleading claims about the use of lasers. To date, research has not shown the laser to be of great value in the removal of calculus below the gum line or on root surfaces. One small study in 1999 found laser therapy to be less effective than traditional scaling and root planing, and it may, in fact, damage the root surface. Nor has it been approved for use on any hard tissue, bone, or teeth. Laser surgery has been approved for soft tissue surgery, for example in gingivectomies (the surgical removal of gum tissue to reduce pocket depth) and frenectomies (the surgical removal of connective tissue and muscular bands of tissue usually located between the upper central incisors). Since these operations are easily performed with the traditional use of a scalpel, however, it is questionable whether the benefits of laser surgery outweigh its high cost.

HOW ARE ANTIBIOTICS BEING USED FOR LONG-TERM PREVENTION OF PERIODONTAL DISEASE

Antibiotics are being investigated in combination with surgery, curettage, or alone to eliminate or prevent disease-causing bacteria after periodontal procedures. A number of antibiotic treatments are being used to help this problem. They are available in oral from or used in devices that are applied locally, directly to the gum. In a 2001 English study, dentists only infrequently used antibiotics, particularly oral forms. Nevertheless, a substantial minority of them believed that local application of antibiotics is more effective than periodontal surgery alone.

Some experts are concerned that long-term use of antibiotics increases the risk of bacterial resistance to these drugs, which is a growing health problem in general. Of some encouragement was a 2000 review of four studies, which indicated that low dose antibiotics do not increase the risk of bacterial resistance. However, long-term studies are still needed

Specific Antibiotics

Tetracycline antibiotics, which include tetracycline hydrochloride, doxycycline, and minocycline, are the primary agents used. They not only have anti-bacterial actions, but also, they reduce inflammation and help block collagenase, the protein that destroys connective tissue and bone, even in low doses. In fact, it is these two actions, rather than their antibacterial properties, which seem to contribute most to periodontal protection.
The antibiotic roxithromycin belongs to the family known as macrolides. It has actions against inflammation and growth involved in periodontal disease.

Direct Delivery of Antibiotics to the Gums

Topical application of antibiotics to the gum surface does not affect the entire body like oral antibiotics do, and they are preferred whenever possible. One study published in 2000 found that local application of doxycycline alone was as effective as scaling and root planing in treating periodontal infections. A number of treatments are available.

Actisite. Actisite is a thin strip similar to dental floss, which is treated with tetracycline hydrochloride.

The treated thread is temporarily inserted between the tooth and gum. (Using multiple strips may be more beneficial than using a single strip.)
Actisite is usually inserted without an anesthetic. Most patients do not experience pain. (In one study, 10% felt discomfort during insertion and 11% reported temporary redness of the area after removal.)
The treated thread releases a steady concentration of tetracycline to the diseased gum tissue. Only a very small amount of the drug is released into the bloodstream, so there are rarely any side effects.
After 10 days the thread is removed.

Clinical trials have shown reduced pocket depth and less bleeding of the gums, which is superior to root planing alone. These benefits seem to last for six months after the thread is removed. One study showed that scaling and root planing plus short-term antibiotic-thread therapy reduced the need for gum surgery and tooth extractions by 88%. After five years, however, there appears to be no difference in periodontal health between the antibiotic group and those who had scaling and root planing alone. While it cannot replace curettage, Actisite provides additional therapy in the treatment of localized periodontal disease.

Other Topical Applications. Other treatments that employ topical antibiotics are under investigation and include the following:

Elyzol is a gel or strip applied to the gum product. It is composed of metronidazole. This agent is not always categorized as an antibiotic, since it has unique actions that are effective against parasites as well as bacteria. In one study comparing tetracycline with metronidazole cellulose strips, tetracycline worked faster but metronidazole achieved a greater bacterial reduction.
Atridox is a doxycycline gel that conforms to the gum surface and then solidifies. Over the next few days, it releases the antibiotics.
A new product called PerioChip is a chip that is placed into the gum pocket after scaling. Over time, it slowly releases chlorhexidine, a powerful bacteria-killing antiseptic. Early studies are reporting benefits in reducing pocket depths, but it is still not known whether these improvements are sustained.
Minocycline microspheres that involve loading the antibiotic into tiny capsules and applying them to the gums are being invested. Studies are now reporting that they are effective in reducing pocket depth and bone loss when used in conjunction with scaling and root planing. Patients obtain these benefits regardless of their smoking status, age gender or extent of the periodontal disease.

Long term results are still unknown for any of these newer procedures.

Oral Antibiotics

Short-term use of doxycycline (a ten-day treatment) is useful for eliminating acute inflammation and infection. The use of oral antibiotics for long-term use has been controversial, except in special circumstances.

Periostat. The first oral antibiotic specifically developed for periodontal disease was low-dose doxycyline (Periostat). The doses are too low to actually fight bacteria but they are sufficient to block the actions of collagenase, the enzyme that destroys the connective tissues holding the teeth. Some studies suggest is improves tooth attachment by 50%. Taking a common nonsteroidal anti-inflammatory drug, such as aspirin or ibuprofen (Advil), along with doxycycline may enhance the effectiveness of this treatment. Periostat is taken for a number of weeks, however, and some experts are concerned that such long-term use may pose a risk for the development of antibiotic-resistant bacteria or other, still unknown, adverse effects.

Metronidazole and Amoxicillin for Chronic Periodontal Disease. One 2000 study reported that a combination of metronidazole plus amoxicillin taken for one week a month for four months arrested disease progression and improved existing levels of chronic periodontal disease. Common side effects include allergic reactions, stomach upset, yeast overgrowth, and sensitivity to sunlight (with tetracycline).

Long-Term Antibiotics for Severe Conditions. Long-term use of antibiotics is advised for the control of juvenile periodontitis, refractory periodontitis, rapidly progressing periodontitis, and prepubertal periodontitis. The most widely used drugs are the tetracyclines and metronidazole (Flagyl). Amoxicillin is also useful.

Keyes Technique

The Keyes technique involves monitoring and controlling specific groups of bacteria to facilitate treatment of periodontal disease. It consists of three major components:

Microscopic monitoring of bacteria in plaque samples.
Local therapy, which includes scaling, root planing, and extensive curettage along with detailed oral hygiene instructions.
Short-term oral antibiotic treatment if results from local therapy are not satisfactory.

While scaling and root planing are known successful treatments against periodontal disease, the benefits of other aspects of the Keyes technique are questionable. Some researchers believe it is too difficult to distinguish disease-producing bacteria from those normally found in the mouth and that microscopic monitoring has been outmoded by new technological advances. Another study reported that knowledge of the bacterial species played no role in treatment outcome. The recommended home care regimen involving hydrogen peroxide and baking soda has been shown to have little or no effect, and may actually damage gum tissue.

WHAT OTHER AGENTS ARE BEING TESTED FOR PERIODONTAL DISEASE?

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs are agents that block factors that cause inflammation and pain. The most common NSAIDs are the following:

Over-the-counter NSAIDs include aspirin, ibuprofen (Motrin IB, Advil, Nuprin, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT). One study suggested that ibuprofen or naproxen is more effective than aspirin or acetaminophen for acute tension-type headache.
Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox, diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), indomethacin (Indocin).
The agents have been investigated not only for pain relief in periodontal disease but in slowing the disease process.
Regular use of even over-the-counter NSAIDs may be hazardous for anyone and has been associated with the following side effects:
Ulcers and gastrointestinal bleeding. This is the major danger with long-term use of NSAIDs. [ See Box Ulcers and Gastrointestinal Bleeding.]
Increased blood pressure. This is a particular problem in those on medications to reduce hypertension. Piroxicam (Feldene), naproxen (Aleve), and indomethacin (Indocin) appear to pose the greatest risks for high blood pressure. (Sulindac has the smallest effect.) People with hypertension, severe vascular disease, kidney, or liver problems, and those taking diuretics must be closely monitored if they need to take NSAIDs.
May delay the emptying of the stomach, which could interfere with the actions of other drugs. The elderly are at special risk.
Dizziness, ringing in the ear.
Headache.
Skin rash.
Depression has also been noted.
Confusion or bizarre sensation (in some higher-potency NSAIDs, such as indomethacin).
NSAIDs may pose a higher risk for kidney injury, which would be of concern in patients with kidney problems. Any sudden weight gain or swelling should be reported to a physician.

Diabetics taking oral hypoglycemics may need to adjust the dosage if they also need to take NSAIDs because of possible harmful interactions between the drugs.

Enamel Matrix Protein Derivative

The gel Emdogain contains amelogenin and is a derivative of a major protein in the structure (the matrix) of enamel that helps stimulate gum tissue growth. It is applied during surgery and forms a coat over the roots of the teeth. The gel itself dissolves after two days, leaving the active substance behind. Studies are reporting that it is safe and may significantly reduce the effects of periodontal disease. A 2001 study suggested that the benefits, as indicated by bone attachment, can persist for at least four years. (Results were similar to guided tissue regeneration.)

Growth Factors

Gels containing growth factors, included substances called recombinant human (rh) platelet-derived growth factor-BB (PDGF-BB) and (rh) insulin-like growth factor-I (IGF-I) are also showing promise for restoring bone.

Vaccines

Research is underway to find a vaccine against periodontal disease. To date, animal studies show promise, but an effective vaccine for people is years away.

WHERE ELSE CAN HELP BE OBTAINED FOR PERIODONTAL DISEASE?

National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health., MD 20892-2290. Call (301-496-4261) or (http://www.nidr.nih.gov/)

National Oral Health Information Clearinghouse, NOHIC Way, Bethesda, MD 20892-3500 (part of NIDR). Call (301-402-7364) or (http://www.aerie.com/nohicweb/)

American Academy of Periodontology, 737 North Michigan Avenue, Suite 800, Chicago, Ill 606ll.

To find a periodontist in a particular region, call (800-FLOSS-EM) or (312-573-3240) or (http://www.perio.org/).

For educational brochures covering the basics of periodontal disease and surgical treatments, send a self-addressed, stamped envelope and request pamphlets on gum disease.

American Dental Association, Department of Information and Education. 2ll East Chicago Avenue, Chicago, IL 606ll.. (http://www.ada.org/)

Academy of General Dentistry. Suite 1200, 211 E. Chicago Ave., Chicago, IL 60611. Call (1-888-AGD-DENT) or (1-888-243-3368). (http://www.agd.org/)

Useful Internet Site

(http://www.webdental.com/)